Nursing Elites

1. A nurse is assessing a patient with schizophrenia who is experiencing delusions. Which intervention is most appropriate?

• A. Agree with the patient's delusions to avoid confrontation.
• B. Encourage the patient to explore the basis of the delusions.
• C. Engage the patient in reality-based activities.
• D. Ask the patient to explain the delusions in detail.

Correct answer: C

Rationale: The most appropriate intervention when assessing a patient with schizophrenia experiencing delusions is to engage the patient in reality-based activities. This intervention helps distract the patient from the delusions and reorients them to the present, promoting grounding in reality. Choice A is incorrect because agreeing with delusions can reinforce them and hinder treatment. Choice B may exacerbate the delusions by delving deeper into their basis. Choice D may not be beneficial as it focuses solely on the delusions without addressing the need to ground the patient in reality.

2. A client diagnosed with major depressive disorder is being educated by a nurse about the use of antidepressants. Which of the following statements by the client indicates a need for further teaching?

• A. I should avoid alcohol while taking this medication.
• B. It may take several weeks for the medication to take effect.
• C. I can stop taking my medication once I feel better.
• D. I should not discontinue the medication abruptly.

Correct answer: C

Rationale: The correct answer is C. The client stating, 'I can stop taking my medication once I feel better,' indicates a need for further teaching. It is crucial for clients with major depressive disorder to understand that they should continue taking their medication as prescribed even if they start feeling better. Stopping the medication prematurely can lead to a relapse of symptoms. Choices A, B, and D are correct statements. Avoiding alcohol while taking antidepressants helps prevent interactions and side effects. Understanding that it may take several weeks for the medication to show its full effect is important for managing expectations. Additionally, not discontinuing the medication abruptly is crucial to prevent withdrawal effects or a recurrence of depressive symptoms.

3. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select one that does not apply.

• A. Limited language skills
• B. Level of cognitive development
• C. Level of emotional development
• D. Parental denial that a problem exists

Correct answer: D

Rationale: Diagnosing mental illness in young children can be complex due to their limited language skills, cognitive development, and emotional development. However, parental denial does not directly affect the child's inherent challenges, making it the factor that does not apply to the difficulty of diagnosis.

4. Which patient should be most carefully assessed for fluid and electrolyte imbalance among those receiving the following drugs?

• A. lithium (Eskalith)
• B. clozapine (Clozaril)
• C. diazepam (Valium)
• D. amitriptyline

Correct answer: A

Rationale: Lithium is known to cause polyuria (excessive urination) and polydipsia (excessive thirst), which can lead to fluid and electrolyte imbalances. Therefore, patients receiving lithium should be carefully monitored for signs of fluid and electrolyte disturbances to prevent any potential complications.

5. A client with bipolar disorder is experiencing a manic episode. Which of the following interventions should the nurse implement? Select one that does not apply.

• A. Provide a structured environment
• B. Encourage rest periods
• C. Limit setting on inappropriate behaviors
• D. Allow the client to engage in stimulating activities

Correct answer: D

Rationale: During a manic episode, it is essential to provide a structured environment to help the client maintain stability. Encouraging rest periods is crucial as excessive activity during mania can lead to exhaustion. Setting limits on inappropriate behaviors helps ensure the client's safety and the safety of others. Allowing the client to engage in stimulating activities can exacerbate manic symptoms by further increasing their energy levels and impulsivity. This can lead to a worsening of the manic episode and potentially risky behaviors. Therefore, allowing the client to engage in stimulating activities is not an appropriate intervention during a manic episode.

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